Rumination and Rumbling on Vascular Access...

As the CEO of the Infusion Nurses Society (INS), Mary Alexander is responsible for managing an international, nonprofit specialty nursing organization by assuring the consistent delivery of professional services to its more than 7,000 members. As the Editor of the Journal of Infusion Nursing, a scientific, research-based, peer-reviewed publication, Ms. Alexander writes bimonthly columns for the journal. She also handles editorial responsibilities for a bimonthly membership newsletter, INS Newsline. She is the Editor-in-Chief of the Core Curriculum for Infusion Nursing, 4th edition and Infusion Nursing: An Evidence-Based Approach. She is also responsible for the credentialing program of the Infusion Nurses Certification Corporation. We asked her to share her views and experiences with us this month.

VC: Tell us a bit about yourself and the Infusion Nurses Society?MA: I began my career as a registered nurse at Massachusetts General Hospital (MGH) in Boston, MA, on a surgical floor, and after 3 years joined the IV team. In fact, MGH was the first to allow a nurse, Ada Plumer, one of the founders of INS, to be responsible for IV therapy administration. She eventually developed the first IV team. My clinical experience as an infusion nurse spans a variety of practice settings, including home care, alternative sites, and acute care settings.

INS was established in 1973 and currently has over 7,000 members worldwide including 40 countries and territories and 3,500 CRNI®s. There is approximately a 50-50 split with INS members practicing in the hospital/acute care settings versus home care and alternative sites. Our mission is to set the standard of excellence in infusion nursing by developing and disseminating standards of practice, providing quality education, supporting research and certification, and advocating for the public, our patients. In order to meet our members’ needs and address nonmember queries, we provide numerous infusion-related resources—from face-to-face meetings, webinars, books, online offerings, position statements, JIN, and more, that can be found on the INS LEARNING Center.

VC: In 2016, INS released an updated version of the Infusion Therapy Standards of Practice with a subtle change to both its title and content. What’s new with this version?MA: The 1st edition of the Infusion Nursing Standards of Practice was published in 1980. With the ever changing healthcare environment, advances in science, and increasingly more complex technology, INS is committed to revising the Standards every 5 years. This reference provides the framework to guide safe infusion practice to ensure the best patient outcomes.

While the title change for the 2016 Standards is subtle, there is a significant distinction. INS recognizes that not one discipline “owns” infusion therapy, but is the responsibility of all clinicians involved with infusion practice. Since infusion care goes beyond nursing, the title was changed to Infusion TherapyStandards of Practice. This change also aligns with today’s interprofessional approach to healthcare.

In this 7th edition, 4 new standards have been added (infusion team, vascular visualization, CVAD tip location, and nerve injuries) and other sections have been expanded to offer more guidance to clinicians. Explanations were added for clarity around the methodology for developing the Standards, including rating the strength of the body of evidence and determining practice criteria recommendations. Of note, the Standards Committee added rating V, “Committee Consensus”. It was applied when there was a lack of literature or very low levels of evidence with conflicting findings. Less than 2% of the practice criteria have this rating.

The 2016 Standards cites 350 more references than the 2011 Standards, a testament to the advancing science and research of infusion therapy. There was also a shift in the rankings of the strength of the evidence, with a 2% increase in Level I rankings (highest rating) and a 21% decrease in Level V (lowest rating) compared to the 2011 Standards. The distribution of rankings has changed thanks to the nature and robustness of the research.

VC: One big difference in the Standards is the recommendation regarding pH and route of therapy. Take us inside the conversations regarding this topic. Tell us more about this update and why it was made.MA: Since 1998, the Standards has viewed pH as a critical factor in vascular access device (VAD) selection. It stated that infusates with a pH less than 5 or greater than 9 are not appropriate for short peripheral or midline catheters. The belief was that infusing those solutions peripherally would increase the incidence of phlebitis and infiltration, therefore implying that a CVAD should be selected in those situations. Recent evidence has shown that there are significant risks associated with CVADs, such as central line-associated bloodstream infection (CLABSI), deep vein thrombosis (DVT), and an increased utilization of unnecessary peripherally inserted central catheters (PICCs).

Committed to evidence-based practice and promulgating standards based on the strongest research available, the Standards Committee reviewed the evidence which was supporting the abandonment of using pH as the sole factor in device selection. As a result, the decision was made to revise the previous statement related to pH and device selection to reflect the current evidence.

VAD planning and selection requires critical thinking, and analysis and decisions should not rely on one factor only. In addition to the pH, the prescribed treatment, duration of therapy, vascular characteristics, and the patient’s age, comorbidities and history of infusion therapy should also be considered.

VC: Many people ask us whether the term infusion nurse and vascular access (VA) nurse are interchangeable? What do you think?MA: There is confusion as to the definition of each role, in particular with patients, families, and caregivers, who may view them as one in the same. However, in my estimation, the terms infusion nurse and VA nurse, are not interchangeable.

A VA nurse is primarily focused on the pre-insertion assessment and the actual VAD insertion procedure. Post-insertion care and management may be limited based on the care setting. For instance, those in a radiology department may only be placing lines, not managing them after insertion.

The specialty practice of infusion nursing has a broader scope. In addition to preinsertion decision making, VAD insertion, and care and management, infusion nurses include additional aspects of care such as medication administration, fluid and electrolyte management, and nutritional and blood component therapy – the infusions going through the VAD. They address VAD complications and the relationships with the sciences of pharmacology, immunology, nutrition, to name a few. Preventing and managing complications from the therapies, along with those from the VAD, are fundamental elements of the specialty. Also, infusion nurses are employed in a wider variety of venues. Often VA nurses are performing procedures in a facility-based setting, while infusion nurses are practicing in all venues—acute care, home care, ambulatory care, and long-term care.

VC: We recently released the MAGIC document to guide vascular access device choice and care. How do you see this influencing infusion and vascular access practice? Did it influence the Standards?MA: The conclusions from the MAGIC document offer constructive guidance for infusion and vascular access practice. It demonstrates that it’s not easy to apply a one-size-fits-all position when dealing with patient care issues. Patient assessment is key, an important aspect of infusion care that INS has long endorsed. The paper also provides a foundation to support practice, not just for the indication of PICC use, but the need to standardize care and maintenance practices based on evidence and research. With an array of different devices and equipment (e.g., visualization devices, ultrasound) to best meet our patients’ needs, clinicians must be vigilant in selecting devices best suited for the patient.

The MAGIC paper was cited as a reference in several Standards, VAD planning, site selection, VAD removal, infection, and CVAD malposition, to name a few.

VC: What are the three biggest challenges you see for infusion and vascular access nursing?MA: First, a major issue is the lack of standardization in clinical practice. Many nurses get little to no infusion education in nursing school, and are expected to be skilled once they’re in practice. Lack of knowledge of the Standards, on-the-job training, and perpetuating traditions not supported by current evidence are factors that jeopardize the ability to prevent risk and provide safe infusion care. Providing curriculum in nursing (and medical) schools to better prepare graduates and increasing awareness of the Standards for application in clinical practice are steps to address this issue.

Second, despite the ubiquitous nature of the specialty, many clinicians don’t recognize the risks associated with infusion therapy. While complications may be local, such as a grade 1 phlebitis, others can be life-threatening. Infusion nurses need to be recognized as key members of the health care team and part of the discussion as it applies to strategic initiatives that impact patient outcomes. In particular, the C-suite needs to recognize the value infusion teams bring to an organization. The business case can be made to support infusion teams and their ability to impact an organization’s fiscal bottom line. Experienced, skilled infusion nurses impact costs—use fewer supplies, less labor, identify complications early and promptly implement treatments.

Third, establishing competencies and maintaining continued competence is a challenge. Clinicians need to stay abreast of the latest research and its impact on practice as well as the introduction of new technology that can enhance care delivery. Patients are living longer, more chronic diseases are being treated, and care is transitioning out of the hospital at a rapid pace. Clinicians must be prepared to competently and safely care for these patients. Standardized education and specialty certification will be vital in addressing these and related issues.

VC: We are a very research-oriented group. What are some of the major questions you see in the field that you think must be addressed by investigators such as us?MA: Based on this “short” list of research questions, your team won’t be at a loss for potential projects!

How do we translate the research and/or accept the evidence-based principles, especially the Standards, into clinical practice? For example, while removal of a VAD is not based on dwell time and is performed when “clinically indicated”, uptake of this practice is still not widely accepted.

With the prevalence of short peripheral and midline catheter use, in lieu of CVADs to prevent CLABSIs, what’s the infection rate with these devices? With limited data on outcomes with midline catheters, what’s the incidence of venous thrombosis? Should we use of a higher level of aseptic technique (sterile gloves, draping) compared to standard practice? Outside of the hospital setting, what are the complication rates of both peripheral and central devices?

Is there a significant risk associated with ultrasound-guided peripheral catheter placement in deeper veins related to vein damage, infiltration and future vascular access?

More studies are needed on maintaining patency of long-term devices, not just the type of locking solution, but how often the device should be locked.

What’s the impact on patient outcomes and safety related to nurse/patient ratios?

The data, evidence, and research are the basis for our practice, validates what we do, and impacts patient care. Adding to the science of infusion therapy can only lead to best practices in infusion care—our patients deserve nothing less!